Title: JUNTOS Project United StatesMexico Effort Towards Tuberculosis Prevention and Control
1JUNTOS Project United States-Mexico Effort
Towards Tuberculosis Prevention and Control
- Fernando J. Gonzalez, M.D., M.P.H.
- Texas Department of Health
- American Lung Association of Texas
- El Paso, Texas
2 Binational TB Prevention and Control Project
JUNTOS
- Tuberculosis History, Pathogenesis. Infection and
Disease. Facts and factors contributing to the
raise, Associated conditions - Border Definition and Contrast of the United
States-Mexico TB Epidemiology - Basic components and activities Project JUNTOS
- Experience with binational TB cases and
- associated binational TB activities
3Historical and Epidemiological Perspective
- Barthel equeleton found near Heidelberd (5000 BC)
- Egipcian momies
- Child momie, Nazca Peru (700BC)
- Hipocrates (460 BC)
- Sylvius, Manget, Marten (Tubercule, miliary and
dinute leving cretures)
4Historical and Epidemiological Perspective
- Sanatorioum Herman Brehmer
- Jean Antonie Villemin TB could be passed humans
to cattle to rabits - Robert Koch discovered MTB, 1882, 1905 Nobel.
- Rontgen X rays
- Calmette-Guerin BCG
- Actinomycin (40), Strept (43), PAS (49), INH
(52),PZA (54) Ciclo (55) ETH (62), RIF (55)
5 United States-Mexico Border
- TUBERCULOSIS INFECTION, DISEASE AND TRANSMISSION
6Tuberculosis Infection, Disease and Transmission
- TB or tuberculosis, is an infectious,
communicable disease that most commonly attacks
the lungs but may occur in almost any part of the
body. The causative agent, Mycobacterium TB
complex (TB, Afr and Bovis), airborne
transmission. ICD-9 Codes 010-018. ICD-10A15-A19.
People who have a () TST but not clinical or
radiological evidence of TB are consider to have
LTBI
7 Tuberculosis Infection and Disease
8 United States-Mexico Border
- Tuberculosis Facts and Contributing Factors to
the Rise
9Tuberculosis Facts
- TB is second biggest killer including 250,000
children - In America half a million cases per year, 75,000
deaths - TB is the biggest infectious disease\ killer
- In the next 20 years 1 billion will be infected,
200 million new cases and 35 million will die
10Tuberculosis Facts
- 75 of the cases productive groups (15-54)
- Vulnerable groups
- Each TB cases losses 3-4 months of work
- TB kills more women than all the other maternal
death causes combined - 95 of the cases and 98 of deaths ocuur in
developing countries
11Tuberculosis Facts
- 30 of the world population have been in contact
- 1 from each 10 will develop TB
- 10-15 infected by each case
- 8 million cases per year
- 20 million cases currently
- 20,00 cases per day
- 1 death each 10 seconds
12Tuberculosis Facts
- Someone in the world is newly infected with TB
every second - Nearly 1 of the worlds population is newly
infected with TB each year - One third of the worlds population is currently
infected with TB - 5-10 infected with TB will become infectious at
some time (NO HIV)
13Tuberculosis Facts
- TB kills about 2 million people each year
- More than 8 million people become sick with TB
each year - About 2 million occur in Sub-Saharan Africa
- About 3 million occur in South east-Asia
- About 250 thousand occur in Eastern Europe
14Factors Contributing to the Rise
15PopulationEl Paso, Texas Ciudad Juarez,
Chihuahua
- Year El Paso Cd. Juarez
- 1900 10,000 8,212
- 1920 22,000 19,457
- 1940 55,024 48,881
- 1960 276,995 270,279
- 1980 625,259 900,000
- 2000 679,622 1,600,000
-
16 Factors Contributing to the Rise
- Freight Private
- Pedestrians Carriers Vehicles
Totals - 2000 5,472,292 725,064 16,645,268
22,842,624 -
- 1999 5,676,087 657,664 15,735,525
22,069,276 - 1998 4,966,406 591,258 15087,443
20,645,107 - 1997 4,400,105 596,538 15,246,499
20,243,142 -
17Factors Contributing to the Rise
- HIV and TB infected is many times more likely to
become ill with TB, than someone infected with
TB-HIV(-) - Poorly managed programs
- a.- poorly supervised treatment
- b.-Incomplete treatments (inconsistent or
- partial)
- c.-Wrong treatments
- d.- Supplies are unreliable
-
18Binational TB Prevention and Control Project
JUNTOS
- UNITED STATES-MEXICO
- BORDER DEFINITION AND LOCATION
19United States-Mexico Border
- The United States-Mexico border extends nearly
1,920 miles (about 3,090 km) between the Gulf of
Mexico and the Pacific Ocean. - The 1983 La Paz Agreement defined the border area
as a corridor extending 100 kilometers on each
side of the international boundary. (Protection
and improvement of the environment in the border
area, 1983).
20United States-Mexico Border
21 United States-Mexico Border
22TB IncidenceUnited States, 1997-2001
23 Reported TB Cases United States, 1981-2001
24Cases per 100,000TB Morbidity Number of TB
Cases inU.S.-Born Vs. Foreign-born Persons,
United States 1991-2001
25 Reported TB Cases, U.S., 2001
26TB IncidenceMexico, 1997-2001
- Year Cases Rate
- 1997 21,957 20.6
- 1998 18,032 18.7
- 1999 16,881 17.2
- 2000 15,649 15.7
- 16,323 16.2
- Cases per 100,000
27Reported TB CasesMexico, 1980-2001
28TB IncidenceU.S and Mexico1997-2001
29 Pulmonary TB Incidence, U.S. and Mexico Border
Status, 2000
30 United States-Mexico Border
- COMPONENTS AND ACTIVITIES
- BINATIONAL TB PREVENTION AND CONTROL PROJECT
- JUNTOS
31COMPONENTS OF THEJUNTOS PROJECT
- Identification of new tuberculosis cases.
- Support current infrastructure of health service.
- Implementation of a binational information
system. - Develop an efficient communication system and
build an electronic binational case registry. - Develop and enhance program for tuberculosis
professional training, health promotion and
disease prevention
32Components and List of ActivitiesDIRECT SERVICES
- Facilitate diagnostic and treatment services
through existing local TB control programs. - Access to primary and second-line drugs.
- Facilitate expert consultation through Texas
Center for Infectious Diseases, South Texas
Hospital, and National Jewish Hospital (Denver). - Expedites referrals to other Mexican health
entities.
33Components and List of ActivitiesDIRECT SERVICES
- Provides DOT and outreach
- Expedites referrals to other Mexican health
entities - Expedites inpatient services to several
Hospitals.
34Juntos Binational Clinical TBCommittee
- Clinical experts meet on monthly basis to
- Offer expert management consultation.
- Facilitate the acquisition of second-line drugs.
- Monitor use of second-line drugs.
- Advocate for the seriousness of the MDRTB
problem. - Review difficult TB cases presented by local
providers.
35Components and List of ActivitiesDIRECT SERVICES
- Smears and cultures are collected and sent for
identification and drug sensitivity testing to
the El Paso Health Department and the Texas State
Laboratory. - Assistance with local HIV testing.
- Provides support for chest X-Ray services.
- Provides support for TST and PPD
36Components and List of ActivitiesDATA ANALYSIS
AND INFORMATION
- Collect demographic information.
- Collect patient information (age, sex,
occupation, family status), data base. - Collect case records.
- Information profiling chronic diseases (diabetes,
immunosuppressive disorders, HIV status, smear
and culture results). - Contact information.
37Components and List of ActivitiesEDUCATION
- TB Conferences (Medical Societies,TCID,ALA,Univers
ities). - TB Reporting workshops.
- TAES (DOT) training.
- DOT Training for Binational Workers.
- Develop, reproduce and distribute promotional and
educational material. - Student Nurse Rotation.
38Components and List of ActivitiesEDUCATION
- Physician Education.
- Group Presentations.
- Interaction with the Media.
- TB Week.
- World TB Day.
- Infection Control Training.
- Thesis Researchs in collaboration with the local
and foreign Schools of Public Health
39Project Juntos A Binational Tuberculosis
Prevention and Control Program
by ROBERT GARCIA THESIS Presented to the Faculty
of The University of Texas Health Science Center
at Houston School of Public Health in Partial
Fulfillment of the Requirements for the Degree
of MASTER OF PUBLIC HEALTH
40Tuberculosis Cases
41Patient Type
42Age Distribution
43Gender
44Birthplace
45Associated Condition
46 Associated Condition Against Gender
47 BCG vaccination Status
48 Treatment Outcome All Patients
49 Treatment Outcome DOT Patients
50Treatment Outcomenon-DOT Patients
51Mean Number of Months in Treatment versus Outcome
52 Multiple Drug Resistance(MDR-TB)
53Treatment OutcomeDrug Resistant Cases
54Treatment Outcome non-Drug Resistant Cases
55Findings/Results
- Project Juntos works with patients that meet at
least one of the criteria of the binational
case definition (CDC, MMWR, January
19,2001/50(RR1)1-2 - Patients are referred to the program by other
health agencies from both countries. - Often patients having associated conditions/risk
factors that particularly have more difficulty in
completing treatment.
56 Findings/Results (Cont)
- For the five-year period
- 15 (4.4) reported having HIV/AIDS
- 61 (17.9) patients reported having diabetes
- 46 (13.5) of the patients reported having a
problem with alcohol - 23 (6.8) patients reported having a problem with
drugs - Note Globally 1 of people are infected with
HIV/AIDS while approximately 6-8 are afflicted
with diabetes.
57 Findings/Results (Cont)
- Patients with alcohol problems were 5.26 times as
likely RR5.26, 95 CI (2.79, 9.94), p-value lt
0.001 to abandon/quit their treatment than
patients without alcohol problems. - Patients with drug addiction problems were 3.11
times as likely RR3.11, 95 CI (1.54, 6.28),
p-value 0.008 (Fisher exact) to
abandon/quit their treatment than patients
without drug addiction problems. -
58 Findings/Results (Cont)
- Cure rate for patients with (difficult to treat)
Multi-Drug Resistant tuberculosis was 43.5,
these patients were 2.58 times as likely
RR2.58, 95 CI (1.21, 5.54), p-value 0.031
(Fisher exact) to abandon/quit treatment than
non-MDR-TB patients - For Project Juntos, the overall cure rate could
possibly be over 80 if the proportion of
patients with alcohol/drug problems or with
MDR-TB were lower. - Note Like in many other countries in the world,
success rates are negatively affected when large
proportions of their tuberculosis patients have
associated conditions.
59 Findings/Results (Cont)
- 200 (58.8) patients reported having been born
in a city other than Ciudad Juárez - 116 patients (34.1) reported having been born in
Ciudad Juárez - Note Population growth in Ciudad Juarez is
primarily due to migration
60 Findings/Results (Cont)
- 116 (34.1) of the patients reported living in
Ciudad Juárez for less than one year while - 132 (38.8) patients reported living in Ciudad
Juárez for more than five years further supports
the view that population growth of Ciudad Juarez
is due primarily to migration into the city - Note It also supports the view that many
patients with TB became infected in a community
other than Ciudad Juarez before migrating into
the city.
61 Findings/Results (Cont)
- After years of steady decline, the increase in
the number of patients enrolled in Project Juntos
during 2001 and 2002 suggests that TB is a
disease that needs continued public health
surveillance and program support. - The overall treatment success (i.e., resulting in
an outcome of cure) for patients enrolled in
Project Juntos during the years 1997-2001
compares favorably with goals set by the World
Health Organization.
62 Findings/Results (Cont)
- The 79.3 microbiologically confirmed cure rate
in Project Juntos is comparable to treatment
results for the most recent worldwide cohorts - From 1995-1999, success rates worldwide have
remained stable at 77-81 under DOT -
63 Findings/Results (Cont)
- Participating Institutes Centers for Disease
Control and Prevention, Pan American Health
Organization, Secretaria de Salud de Mexico. - Conclusion Project JUNTOS success and
accomplishments are due to the dedication and
hard work of many people on both sides of the
border. Valuable and needed services have been
made available to TB patients by Project /JUNTOS. - Communication and collaboration between TB
health providers in Mexico and the US have also
been strengthened through Project JUNTOS efforts.
64 United States-Mexico Border
- ASSOCIATED ACTIVITIES
- BINATIONAL TB PREVENTION AND CONTROL PROJECT
- JUNTOS
65 Migrant Clinicians NetworkTBNet
- Binational TB patient tracking and referral
project - Created for migrant farm workers, know it is
expanding to include homeless, immigration
detainees, prison parolees or anyone moving
during their treatment - Facilitates the tracking and transfer of records
of those patients and notifies the enrolling
clinic that the patient has completed treatment
66 Migrant Clinicians NetworkTBNet
- Five months 10/20/03 to 03/20/03
- Cases managed 59
- Active TB 34 LTBI 25
- Countries Mexico, Spain, Guatemala, Korea, Ivory
Coast, China, Ecuador, Indonesia, Nigeria,
Moroco, Thailand, Russia
67 United States-Mexico Border
68 U.S.-Mexico Binational TB Referral and Case
Management Project
- The Binational Health Card is the product of the
political support of both countries and takes
into consideration the existing experiences of
other binational referral projects such as CureTB
and TBNet.
69CURE TB
- Began locally in 1997 and now serves all states
throughout the U.S. and Mexico - Main focus is to provide referrals for
suspect/active cases traveling between the U.S.
and Mexico for continuity of care. - Operates via a 1-800 number for patients in both
countries and for providers in Mexico without
access to international dialing.
70Websites
- www.cdc.gov/nchstp/tb/
- www.migrantclinician.org/programs/TBNet/tb_article
s.html - www.curetb.org/
- www.tdh.state.tx.us/default.htm
- www.r10.tdh.state.tx.us/
- www.texaslung.org
71 - La migración hace del migrante un ciudadano del
mundo - Beato Juan Bautista Scalabrini
- Juntos
- ..Podemos lograr la diferencia